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On Outcomes and Humility

The competency movement in medical education asserts itself in every corner of students’ experiences from matriculation through residency. Such a focus on making sure trainees achieve desired levels of skills, knowledge, and technique is highly desired by the patients they will be servicing, but educators’ need to turn nearly every dimension of medical education into a competency is an ill-advised leap that transforms a complex educational mission into a bottom-line venture. This commentary provides a critical examination of the wholesale use of competency measures in academic medicine, using the concurrent articles by Murray-García and García about multiculturalism and by Kumagai about narrative medicine as thoughtful examples of educational efforts that turn away from this narrow orientation, focusing instead on the ongoing reflective processes and humility that mark the lifelong development of skilled, empathic physicianhood.

Editor’s Note:This is a commentary on the following articles, which appear in this issue of Academic Medicine: Murray-García JL, García JA. The institutional context of multicultural education: What is your institutional curriculum? Acad Med. 2008;83:646–652. Kumagai AK. A conceptual framework for the use of illness narratives in medical education. Acad Med. 2008;83:653–658.

People are always checking up on each other. - —Michael Power, The Audit Society: Rituals of Verification

Melanie Tervalon and Jann Murray-García1 transformed the way I think about multiculturalism in their 1998 article, “Cultural humility versus cultural competence: A critical distinction in defining physician training outcomes in multicultural education.” Like these authors, I am uneasy with the narrow checklists of many cultural competency approaches, but their insertion of humility into the conversation went far beyond my thinking on the subject. They suggested that trainees should spend less time memorizing or performing at preset determinations of competence and more in “a process that requires humility to develop and maintain mutually respectful and dynamic partnerships with communities on behalf of individual patients.”1(p118)

How have we arrived at a place where competence has seemingly leaked into every area of academic life? It makes perfect sense in areas where we expect trainees to achieve a desired level of skill, information, or technique, but when we apply the same reasoning to habits of thought and feeling beyond the operational and instrumental, we make a wrong turn, drawn by our lust for assessment. Strathern2 describes this as the “domaining effect,” a phenomenon where the logic associated with one domain is appropriated by another. For example, this effect is at play when we identify very specific clinical skills that medical students should have mastered and assess whether they have acquired them in a clinical competency exam, then extend this logic and subsequent assessment to other areas such as empathy or respect for patients. Instead of focusing on the nuanced, complicated, and context-driven nature of empathy and respect with our students, we often rush to identify certain knowledge-based or behavioral manifestations associated with these virtues and develop various evaluative measures to “test” for evidence of their presence using baseline standards. Then we cross them off the list as a competence “achieved,” moving on to the next arena. Never mind that this undertaking is conceptually thin, or that false assurances may result from such assessment.3(p587)

But a growing number of medical educators are braving the current competency tsunami by providing a lively counterdiscourse to its tenets. In his sardonically titled article “Monkey see, monkey do,” Talbot3(pp587–588) refers to a “messianic fervor” surrounding the “minimalist discourse of competency,” the results of which run the “serious risk of negating a deep and reflective engagement” with the professional practice of medicine. Barnett4(p80) warns that “we are beginning to see signs of professional education narrowing to sets of practical skills—indeed, to competencies—and behavioural operations, with [patients] reduced to being recipients of those skills rather than joint authors of the professional services they require.” Grant5(p272) suggests that “while we talk about competence we might not notice the professional culture being dismantled” and wonders how this discourse “managed [to] get such a grip in a profession which, quite rightly, prides itself on its intellect, its judgment and its independence.” She continues:

The sum of what professionals do is far greater than any of the parts that can be described in competence terms. They are making judgments, managing cases in the absence of definitive information, taking a multiplicity of factors into account, dealing with each case on its own merits, almost never replicating precisely the same approach because every case is never exactly like any other. The application of a corpus of knowledge with judgment to an individual [patient] situation is the essence of professionalism.5(p273)

But there are exceptions to this trend. The authors of two articles in this issue of Academic Medicine offer thoughtful, conceptually incisive observations on educational projects that steer clear of such reductionism. In “The institutional context of multicultural education: What is your institutional curriculum?” Murray-García and García6 dismiss our propensity for “digestible ‘units’ of multicultural education or ‘cultural competence’ training” that seek to “‘fix’ or ‘fill up’ what is lacking” in trainees while remaining silent or ignoring institutional variables that work directly against such efforts. They suggest that “few have taken a critical perspective on how [the] individual trainee must learn, change his/her behavior, and sustain that behavioral change within a specific institutional context.” This is no small point, and it is one that is often ignored in multicultural education and professionalism efforts in the curriculum, particularly those that involve competencies. As I have argued elsewhere,7(p1059) many models of professionalism “do not take into account the social and political effects of organizational hierarchies in medical institutions … [that] cannot be separated from a student’s experience.” Murray-García and García turn our attention to such institutional factors, rather than placing all the responsibility on students, to show that the competencies educators wish to teach toward may in fact be subordinated or even ignored in the larger institutional culture.

In “A conceptual framework for the use of illness narratives in medical education,” Kumagai8 describes an approach to patient-centered medical education and narrative medicine, the Family Centered Experience at the University of Michigan, that is thoughtfully grounded in theories of empathy and moral development. By focusing on narratives of all kinds—foremost, face-to-face interactions with individuals with chronic illness—but also stories and films, with perspective-taking exercises, reflective essays, and other interpretive projects, a learning environment is created that offers students entry into the subjective experience of illness. Such experiences may evoke “empathetic” and “sympathetic” distress, along with “hot cognitions” that are “situations in which the plight of another person triggers the recollection in the observer of a similar event or situation in his or her past.” According to Kumagai, this many-sided approach may be applied to curricula focusing on narrative medicine, professionalism inquiry, multicultural education, and bioethics.

Kumagai focuses not on empathic “competencies” but on “shifts in students’ perspectives toward more humanistic, patient-centered approaches to medical care.” In addition to students’ interpretive writing and other projects, qualitative methods such as focus groups are used to explore the meanings students confer on the life experiences of their patients and themselves—a pursuit marked by open-endedness, not distinct knowledge, action, or preset external standards for evaluation. Students’ essays and contributions to classroom discussions are evaluated by the “depth and quality of their understanding and insights regarding the patient’s experience of illness, as well as their readiness to engage in self-reflection as part of the learning process.” Moreover, patients provide feedback on students, becoming cocreators with “experts” in determining what counts as caring, respectful practice. In his perceptive book, The Limits of Competence, Barnett4(p73) weighs in on the importance of this thoughtful orientation:

What counts as good practice in social work, the law, medicine and so on are contested goods: the public generally—as potential claimants of the service—and other groups have legitimate voices…. Any attempt, therefore, to draw up a list of competences is bound to be partial and debatable. To any such list of competences we are entitled to respond: whose competences are these?

This question may lead us away from experts and benchmarks, and back to where I began with the overlooked virtue of humility in medical education and medical care. While the Oxford English Dictionary defines humility as “having a lowly opinion of oneself; meekness, lowliness, humbleness,” some scholars use it in an alternative way that has great relevance to our efforts in fostering empathic, respectful, culturally informed care in our trainees. Drawing from philosophy, theology, and other disciplines, Tangney9(p73) suggests that humility can also denote a willingness to accurately assess oneself and one’s limitations, the ability to acknowledge gaps in one’s knowledge, and an “openness to new ideas, contradictory information, and advice.”

This is not the stuff found in the discrete endpoints of competency training that often negate the importance of a deep, ongoing, reflective practice by asking questions whose answers may be easier to measure. However useful such end points are to determine requisite knowledge and skills involved in patient care, they are insufficient without a simultaneous and ongoing process of humble reflection on how one’s knowledge is always partial, incomplete, and inevitably biased. The two articles published here illuminate such processes, not just for trainees but for their teachers as well. Without enactments of humility in the learning environment—in the institutional policies, in role modeling, in curriculum projects and modes of assessment—it is no wonder that students fall into the “mission accomplished” mindset of competency-based education.

One of the characters in Nicole Krauss’s10 beautiful novel, A History of Love, asks, “When will you learn that there isn’t a word for everything?” Can we acknowledge the same in medicine, or must everything be named, counted, and evaluated?